Savings + GPA + Group Term Account Opening ... - DCB Bank

Account Opening Form(Savings + GPA + Group Term)For Individuals144-Ver 1.0-Apr 2013 Development Credit Bank LimitedM005 / Apr 13 / 1.0

Nomination Details (Form DA 1)Yes, I want to nominate the following personNo, I do not want to nominate anyone on my behalfI nominate the following person to whom in the event of my / minor’s death the amount in the account may be returned by Development Credit Bank Limited.Nominee Name:Address:Relationship with Applicant, if anyAge:YearsNominationDate of Birth:DDMMYYYY* As the nominee is a minor on this date, I appoint (Name & Address)Nominationunder Section45ZA of theBankingRegulationAct, 1949and Rule 2(1) ofthe BankingCompanies(Nomination)Rules 1985 inrespect of bankdeposits.to receive the amount of the deposit / in the account on behalf of the nominee in the event of myminor’s death during the minority of the nominee.In case you have specified a nominee above, please indicate if you wish to make mention of thenominee name on the passbook, statement & DCA issued in respect of your account and / or thepassbook issued to youYes NoI do hereby declare that what is stated above is true to the best of my knowledge and belief.Witness:Name :Name :** Signature(s) / Thumb Impression(s) of Applicant(s)Thumbimpression isrequired to beattested by2 witnesses.In case ofsignature, nowitness isrequired.Signature :Address :Signature :Address :Place :Date :Place :Date :* Strike out if nominee is not a minor. ** Where deposit is made / account is held in the name of the minor the nomination should be signed by a person lawfully entitled to act on behalf of the minor.Form 60 / 61(to be filled by those who do not have either PAN or GIR) In case of Agriculture Income, please fill up form 61 separately.Form 601. Full name and address of the Declarant:2. Particulars of transaction:3. Amount of the transaction:4. Are you assessed to tax: Yes No5. If Yes,a) Details of Ward / Circle / Range where the last return of income was filed:b) Reason for not having PAN / GIR No.:6. Details of the document being produced in support of address in column (1):VerificationI, hereby declare that whatis stated above is true to the best of my knowledge and belief. Verified today,the day of 20Date:Form 61 [See provision to clause (a) of rule 114C(1)]Form of declaration to be filed by a person who has agricultural income and is not inreceipt of any other income chargeable to income-tax in respect of transactionsspecified in clauses (a) to (h) of rule 114B.1. Full name and address of the Declarant:2. Particulars of transaction:3. Details of documents being produced in support of address in column (1):YesNoI, herebydeclare that my source of income is from agriculture and I am not required topay income-tax on any other income if any.Date :Place :VerificationSignature of the DeclarantI, hereby declare that whatis stated above is true to the best of my knowledge and belief. Verified today,the day of 20Date:Place:Signature of the DeclarantPlace:Development Credit Bank LimitedSignature of the Declarant5

Birla Sun Life Insurance Company LimitedRegistered Office: One Indiabulls Centre, Tower 1, 16th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai - 400 013.Call Centre: 1-800-270-700 www.birlasunlife.comRegistration No. 109For Internal Use Only0 0 1 0 9 7BSLI Group Protection SolutionsENROLMENT FORM(All fields are mandatory and need to be filled in bold letters)Corp. Agent No.: Customer Id: Location:DCB Bank RM Name: USM Code: ASM / RSM Code:UIN No.: 109N006V03DCB Bank RM Id:SM / SSM Code:ZSM / RH Code:Branch Code:Form No.:D C B 2 0 0 0 1A) Member InformationName of the Master Policy Holder:D E V E L O P M E N T C R E D I T B A N K L I M I T E DMaster Policy Number: 5 0 2 1 5 2Name of the Member / Life Insured:Date of Birth:D D M M Y Y Y Y Age: Years Gender: Male FemaleAddress for Communication:City:Pin:Landmark:State:Nationality:PAN No.:Email Id:Nominee Name:(Copy of Pan card is mandatory)Country:*Preferred Mobile No.:Telephone:(with STD Code)Relationship with Member: Spouse Son Daughter Father Mother Brother SisterAppointee / Guardian Name: (In case of Nominee is minor)Relationship with Nominee:B) Details of Development Credit Bank Limited RelationAccount No.:Type of Account:DCB Elite / PrivilegeOthersAre you already covered/ applied for any of the BSLI Group plans through Development Credit Bank Limited?If 'Yes" please provide the details / COI numberYesNoC) Sum Assured & Premium Payment DetailsSum Assured: `(In multiples of ` 5 lakhs only / ` 37,50,000 applicable for Non Elite / Privilege Members)Premium Amount: `• Service Tax payable additionally at prevailing rates.• Premium rates are level and guaranteed for in-force business for 5 years from the date of entry.• 6th policy year onwards the renewal of the coverage shall be affected as per prevailing premium rate table, ageof Member at the time of such renewal and terms and conditions mutually agreed upon between the Companyand the Group Policyholder.• There is no age set-back for female lives.Service Tax: `Total Premium: `Premium is as per the premium calculatorI am aware that the withholding of, or omission or failure to disclose or incorrect disclosure of any medical or financial information will invalidate the policy term and this enrolment form.Declaration of Good Health1. Personal Details of the Life to be Insureda. Do you smoke more than 10 cigarettes or consume more than 5 pouches of chewing tobacco / Gutka per day?YesNoInitials7b. Do you consume more than 2 drinks of alcohol per day or more than 10 drinks of alcohol per week?c. Have you ever been asked by your family doctor or any physician to reduce your weight or have you lost morethan 10 kgs of weight without exercise during the last one year?2. Have you been absent from work due to any illness or injury for a continuous period of more than 7 days duringthe last 5 years or have you consulted any doctor for treatment of any ailment other than common cough or cold; orundergone any hospitalization at a hospital or a clinic for treatment of any condition; or undergone any investigationwith other than normal or negative results (including X rays, ECG, blood tests, biopsies etc.) in last 5 years?Development Credit Bank LimitedYesYesYesNoNoNoInitialsInitialsInitials

3. Have you ever been diagnosed with or received treatment for any disability or medical conditions such as but notlimited to high cholesterol, high blood pressure, chest pain, heart attack or any other heart condition; stroke,transient ischemic attack or any other cerebrovascular disease; diabetes or any other endocrinal disease; kidneydisease; HIV/AIDS or AIDS related complex; any cancer or tumor; asthma or any other respiratory disease; anymental or nervous disease; hepatitis or any other liver disease; blood disorders; digestive and bowel disorders;gynecological problems or pregnancy related complications; paraplegia or any other disorder of the bones, spineor muscle?4. Has any proposal for life, health, accident or critical illness including renewal and revival of lapsed policy ever beendeclined, deferred or accepted at special rates or term by BSLI or any other insurance company? Or have you evermade a claim against a critical illness or surgical benefits insurance policy?5. Have you engaged or intend to engage in any hazardous sport, activity, hobby, business or occupation includingbut not limited to scuba diving, mountaineering, rock climbing, bungee jumping, paragliding, flying when not as afare paying passenger, motor racing, etc?6. Has any member of your immediate family e.g. parents, brothers, sisters, suffered from heart disease, stroke,cancer, kidney failure, organ transplant or any other chronic or hereditary conditions before the age of 60 years?Yes No InitialsYes No InitialsYes No InitialsYes No InitialsDeclaration by the Life to be InsuredI declare and warrant that this Personal Statement is complete and true, and also that I understand and agree that this statement together with the application for insurance on my life and any other documentsrelative thereto, shall be the basis of the proposed coverage. I am aware that the withholding of, or omission or failure to disclose or incorrect disclosure of any medical or financial information will invalidate myCertificate of Insurance. I agree to inform BSLI in writing of any change in my circumstances between the date of this proposal and the issue of the Certificate of Insurance. I irrevocably authorise and requestany doctor or any other person who may be in possession of, hereafter acquire, any information concerning my health, to disclose such information to BSLI and I agree that this authority and request shallremain in force.I agree that my Development Credit Bank Limited account through which I have enrolled for this policy will be automatically debited for the initial and renewal premium due for this policy. I agree andacknowledge that if I opt for non-renewal of this policy, I will ensure that Development Credit Bank Limited has been informed (in writing) at least 15 (fifteen) days prior to the date of renewal of the policy. In theabsence of receipt by Development Credit Bank Limited (the “Bank”) of such instruction, it shall be construed by the Bank that I have opted for automatic renewal/auto debit to my bank account towardsrenewal of the existing policy. If my said bank account is closed for any reason, then this policy cannot be renewed on automatic renewal basis. I understand that I need to ensure that my said bank account hassufficient cash balance to enable the Bank to carry out the standing instruction. I agree to keep the Bank fully indemnified and held harmless at all times, from and against all claims, expenses, losses, damages,costs (including reasonable attorney's fees), actions, suits and proceedings arising due to non-execution or delays in execution of my standing instruction due to inadequate balance in my said bank accountor for any other reason beyond the control of the Bank. I hereby authorize the Bank to charge my said bank account towards the payment of the premium towards this policy and pass on the proceeds to theinsurance company. This debit will stay authority in force till such time that I make a representation to cancel the said instruction. I understand that the Bank will earn 7.5% of net premium as first yearcommission on this policy in their capacity as the licensed Corporate Agent of Birla SunLife Insurance Co. Ltd. (BSLI).Date:D D M M Y Y Y Y Place: Signature of the Member:Name of the Witness:Signature of the Witness:(Witness signature is mandatory if the member has signed in vernacular language)Terms & ConditionsCompletion of this form does not imply that a policy for insurance on the member to be insured will be issued by BSLI.The cover will commence only from the date the premium received by BSLI.Your coverage details and term will be mentioned in certificate of insurance issued by BSLI.This is a Group Term Policy and not a Mediclaim, Fixed Deposit (FD) or a normal life insurance with profits contract.Renewal of the coverage shall be affected as per prevailing premium rates, age of member at the time of such renewal and terms & conditions mutually agreed upon between BSLI and the Group Policy Holder.The premium rates for in-force coverage are guaranteed for the five (5) years from the date of entry and are reviewable thereafter. Changes in premium rates (if any) shall be intimated to member prior to therenewal due date.Please ensure that you read the declaration in detail and understand its implications before signing the same. Claims may be rejected in case the declaration signed at the time of enrolment is proved to befalse. The enrolment form shall be rejected, in case member is not fulfilling the eligibility criteria or there is receipt of incomplete documents.Health Declaration filled by the Member / proposed life insured is valid for 90 days.Waiting Period – No Life Insurance cover shall be available during a period of 45 days starting from the Coverage Effective Date, except for death due to accident.Free-Look Period – The insured Member has the option to cancel the coverage within 30 calendar days from receipt of Certificate of Insurance (COI) by giving BSLI, in writing, the reason for objection. In sucha case, BSLI will cancel the coverage for the Member and shall return premiums paid by the Member after deduction of expenses incurred by BSLI (including stamp duty) in accordance with IRDA (Protection ofPolicyholders Interest) Regulations, 2002 provided:i. Written notice for cancellation, together with the original COI has been received by BSLI; andii. BSLI has not received any claim intimation.Suicide – If the member under this coverage dies by suicide, whether medically sane or insane, within one year after the Coverage Effective Date BSLI will not pay the amount described in the Death BenefitProvision. In such circumstances the Premium(s) received would be refunded, without interest, after deducting expenses incurred by BSLI. Kindly refer to the broucher and certificate of insurance (COI) forother exclusions.Kindly refer to the brochure and Certificate of Insurance (COI) for other exclusions.Section 45 of Insurance Act, 1938:No policy of life insurance effected after the coming into force of this Act shall, after the expiry of 2 years from the date on which it was effected be called in question by an insurer on the ground that statementmade in the proposal or in any report of a medical officer, or referee, or friend of the life insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows thatsuch statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policyholder and that the policyholder knew at the time of making it thatthe statement was false or that it suppressed facts which it was material to disclose. Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so,and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the application. As perSec 45 of the Insurance Act 1938, I understand and agree that the answers and statements made on this Health Declaration are full, complete and true in every particular and will form the basis of the contract,which may arise. All material facts, being facts, which may influence the assessment of this risk, have been disclosed in this Health Declaration, it being understood by me that failure to make such disclosurerenders the contract voidable.Section 41 of Insurance Act, 1938:No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India,any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except suchrebates as may be allowed in accordance with the published prospectus or tables of the insurer. Any person making default in complying with the provisions of this section shall be punishable with a fine whichmay extend to five hundred rupees.DisclaimerInsurance products are obligations only of the Insurance company. They are not bank deposits or obligations of or guaranteed by Development Credit Bank Limited, or any of its affiliates or subsidiaries or anyGovernmental agency. All Claims under the policy will be solely decided upon by the Insurance Company. Development Credit Bank Limited or any of their affiliates and group entities hold no warranty and donot make any representation about the insurance, the quality of claims processing and shall not be responsible for claims, recovery of claims, or for processing of or clearing of claims, in any mannerwhatsoever. Insurance is the subject matter of solicitation. This document does not constitute the distribution of any information or the making of any offer or solicitation by anyone in any jurisdiction in whichsuch distribution or offer is not authorized or to any person to whom it is unlawful to distribute such a document or make such an offer or solicitation. Investment products are not available to US persons andmay not be available in all jurisdictions. *IRS Circular 230 Disclosure: Development Credit Bank Limited, its affiliates, and its employees are not in the business of providing tax or legal advice to any taxpayeroutside of Development Credit Bank Limited and its affiliates. This enrolment form is not intended or written to be used, and cannot be used or relied upon, by any such taxpayer for the purpose of avoiding taxpenalties. Tax benefits are subject to changes in the tax laws. Any such taxpayer should seek advice based on the taxpayer's particular circumstances from an independent tax advisor. Development CreditBank Limited is a licensed Corporate Agent of Birla Sun Life Insurance Company Limited under the composite license number 947901. Life Insurance policies are underwritten by Birla Sun Life Insurance CoLtd. with its registered office at One Indiabulls Centre, Tower 1, 15th &16th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013, Reg. No. 109. For more details on riskfactors, terms and conditions please read the sales brochure carefully before concluding the sale.Development Credit Bank Limited8

BSLI Group Protection Solutionfor Development Credit Bank Limited CustomersSerial Number:Relationship Manager's Name:Employee ID:Branch:I provide my consent to enroll for BSLI Group Protection SolutionStanding Instruction for BSLI Group Protection Solution payment through Development Credit Bank LimitedDate of Application:D DMMYYYYName of the Account HolderDate of Birth (of the Account Holder):Debit to`DDevelopment Credit Bank LimitedAccount NumberTotal premium plus Service Tax for member on BSLI Group Protection SolutionDMMYYYRupees (in words):YCity in which account is held:Initial premium due to BSLI Group Protection SolutionsRenewal premium due to BSLI Group Protection Solutions paid annuallyTerms and Conditions: I understand that the entire amount of premium needs to be paid for the enrolment to the master policy for the insurance cover to come in force. That I need to ensure thatmy said account needs to be funded with appropriate amount to enable Development Credit Bank Limited (the “Bank”) to carry out the standing instructions. I agree to keep the Bank and insurancecompany fully indemnified and hold harmless at all times, from and against all claims, expenses, losses, damages, costs (including reasonable attorney fees) actions, suits and proceedingsarising due to non execution or delays in execution of my standing instruction either on account of non availability of sufficient funds in my account or delay in mail/courier services or for any otherreason beyond the control of the Bank.I hereby authorize the Bank to debit my above mentioned bank account towards the payment of the initial /renewal premium(s) towards my Birla Sun Life Insurance (BSLI) Group ProtectionSolution policy and pass on the proceeds to BSLI. In case of auto renewal of the said policy, this Standing Instruction (SI) will automatically be in force till such time I intimate in writing to the Bank tocancel the same.I am aware that on the renewal of the policy, the renewal premium is subject to change, basis relevant age band and service tax rates, as amended by Govt. of India, Ministry of Finance from time totime.I hereby agree and confirm that I have read and understood the terms and conditions and disclaimers given above.Date:DDMMYYYYSignature of the Account Holder:A worldwide personal accident cover plan that is specially designed to give comprehensive protection to help you / your family against financecrises due to Accidental Death or Permanent Total Disablement.Key Features: • Worldwide Cover • No Waiting PeriodSum Insured Options:Death + Permanent Total DisabilityDeath + Permanent Total Disability + Double benefit for salaried person for accidenton duty by Rail / Road / AirSum Insured ` Premium ` Option Chosen (þ) The maximum5,00,000500Sum Insuredallowed for any15,00,0001,800one customer,across one or25,00,00030,00,0003,0003,600more policies,should notexceed15,00,0002,000` 30 Lakhs(standard25,00,0003,300variant only).Key Benefits:Death Benefit: In the unfortunate event of a fatal accident, the Sum Insured shall be paid to the nominee of the Insured Person.In the unfortunate event of an accident resulting in Permanent Total Disability, the Insured Person shall be paid the following % of Sum Insured.a) 100% sum insured in case of loss of sight of both eyes, or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand and one entire foot, of such lossof sight of one eye and such loss of one entire hand or one entire foot.b) 100% sum insured in case of loss of use of two hands or two feet or of one hand and one foot, or of such loss of sight of one eye and such loss of use of one hand or one foot.c) 50% sum insured in case of loss of sight of one eye, or of the actual loss by physical separation of one entire hand or of one entire foot.d) 50% sum insured in case of total and irrecoverable loss of use of a hand or a foot without physical separation.e) 100% sum insured in case of permanent and total disability which absolutely disables insured person from engaging in any employment or occupation.For those opting for Double benefit for Death & Permanent Total Disability cover: Claim will be paid for salaried persons who are involved in an accident on duty while traveling by Rail / Road / Air.Who can be Insured Person?This insurance is available to persons who are aged between 18 and 70 years at the commencement date of the Policy and are Account holders of Development Credit Bank Limited (DCB Bank).This is an insurance plan underwritten by Royal Sundaram Alliance Insurance Co Ltd. for customers of DCB Bank. Your participation in this insurance product is purely on a voluntary basis. DCBBank will be the Group Manager for this insurance product and will only be responsible for distributing the insurance product to all members of this group. All Claims under the policy will be solelydecided upon by Royal Sundaram Alliance Insurance Company Ltd.This application shall be processed and the premium amount as per option chosen by you shall be debited if it is found acceptable by Royal Sundaram Alliance Insurance Company Limited. Theinsurance cover shall start on 1st day of succeeding month of the premium amount debit in your DCB Bank Account (“commencement date”). This insurance cover will be valid for a period of 1(one) year from the commencement date, provided you continue to remain a DCB Bank account holder during this period. This insurance cover will cease to exist in case the DCB bank Account isdormant, freezed or lien marked for any reason whatsoever. The application will not be accepted till the time such account related disputes are resolved and the said DCB Bank Account isreactivated. Renewal reminders for this policy will be conveyed through SMS alerts and Email by DCB Bank on your registered Mobile No. and Email ID respectively.If for any reason you need to communicate with Royal Sundaram Alliance Insurance Company Limited, it is adequate that you mention the Master Policy number, DCB Bank account number andthe branch details. Claim intimation can also be made to Royal Sundaram Alliance Insurance Company Ltd, by contacting them on 1860 425 0000.This is only a brief summary of the insurance product. Please refer to Master Policy No. PADCB00001 (available on DCB Bank’s website www.dcbbank.com) issued to DCB Bank by RoyalSundaram Alliance Insurance Company Limited for complete information on terms, conditions and exclusions.Royal Sundaram Alliance Insurance Company Limited, Sundaram Towers, 45 & 46, Whites Road, Chennai - 6000149

DCB Elite Current Account§ Choose your lucky number as your account number.§ Unlimited free RTGS / NEFT / DD / PO / PAP Cheque Book.Terms and conditions apply.Development Credit Bank LimitedDCB 24-Hour Customer CareEmail customercare@dcbbank.comCall 3281 1322 < Toll Free 1800 209 5363Website www.dcbbank.comACKNOWLEDGMENTName of the Applicant:DCB Bank Account Number:DCB Bank Account Opening Form Number:Date:DDMMYYYYInstruction received to debit ` ______________ from DCB Bank Account towards Group Personal Accident Insurance Premium.(Note: Certificate of Insurance will be couriered at your mailing address / emailed on your registered Email ID post issuance of the policy. Insurance cover will start on 1st day of succeeding month of the premiumamount debit from your Account with Development Credit Bank Limited)This application is for Group Personal Accident Insurance Cover only. It is not a cover for Life Insurance or Mediclaim.Applicant’s Signature: ____________________________________Authorized signatory for Development Credit Bank Limited: ____________________________________List of hazardous occupation which are not covered in GPA:Aircraft pilots and crew, Armed Forces personnel, Artistes engaged in hazardous performances, Aerial crop sprayer, Bookmaker (for gambling), Demolition contractor, Explosivesusers, Fisherman (seagoing), Jockey, Marine salvager, Miner and other occupations underground, Off-shore oil or gas rig worker, Policeman (Full time), Pop Musicians, Professionalsports person, Roofing contractors and all construction, maintenance and repair workers at heights in excess of 50ft / 15m, Saw miller, Scaffolder, Scrap metal merchant, Securityguard (armed), Steeplejack, Stevedore, Structural steelworker, Tower crane operator, Tree feller, Ship crew, Travel agency business, Air coupon & ticket business.Royal Sundaram Alliance Insurance Co. Ltd.Call 1860 425 0000Write customer.services@royalsundaram.inVisit www.royalsundaram.in10

DeclarationI have read, understood and hereby agree to the “Terms and conditions as applicable to my account” set forth on Development Credit Bank Limited (“DCB Bank”, “the Bank”)website at www.dcbbank.com. I understand that access to any changes / updates in terms and conditions applicable to this relationship shall be available on the Bank’s websiteonly. I do hereby declare that information furnished in this Form is true and correct to the best of my knowledge and belief. I hereby authorize issuance of ATM / Debit Card andprovision of Phone Banking, Mobile Banking Services, Internet Banking and Bill Payment Services. I am aware of Charges Applicable for various services offered and I affirm,confirm and undertake that I have read and understood the “Terms and Conditions” for usage of the Phone Banking, Mobile Banking Services, Internet Banking and Bill PaymentServices of DCB Bank as set forth in the Bank's website www.dcbbank.com and I will adhere to all the terms and conditions as applicable from time to time. I further authorise theBank to debit my Account(s) towards any applicable charges for any / various service / services provided as applicable from time to time.*I understand and agree that the consent given for updation / registration / requests for free Mobile alert facility shall be valid till such time I withdraw the same in writing. Unlessspecifically advised, the Bank will continue to send SMS alerts on the number requested by the Authorised signatory/ies of the Firm / Company / Trust / Association / Society. TheBank shall not be responsible and liable for any consequences which may arise owing to change in name/s of authorized signatories or partners or directors or trustees ormembers of the Firm / Company / Trust / Association / Society.I declare, confirm, understand, accept, acknowledge and agree:a) That all the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in allrespects and I have not withheld any information. I understand certain particulars given by me are required by the operational guidelines governing banking companies. I agreeand undertake to provide any further information as and when the Bank may require. (b) That I have had no insolvency proceedings initiated against me nor I have ever beenadjudicated insolvent. (c) That I have read the application form and brochures and am aware of all the terms and conditions of availing finance or service or products from theBank. (d) That the Bank reserves the right to reject any application without providing any reason and reference to me. I agree and understand that the Bank reserves the right toretain the application forms, and the documents provided therewith, including photographs, and shall not return the same to me. (e) To inform the Bank regarding change in myresidence /employment and to provide any further information as and when the Bank may require from time to time. (f) That if the Account is under Corporate salary Scheme: • Ihave also read and understood “Terms and Conditions” under which Salary Scheme is offered to my organisation and employees.• I agree that my employer has full right toreserve any instruction given by them to credit my account for any amount within a period of three working days and I will not dispute or hold the Bank responsible for suchdebits in my account. • I understand that it is my responsibility to inform (in writing) the Bank immediately on termination of my employment with my current employer,whereupon I will cease to enjoy any or all benefits under Salary account scheme. (g) That I shall not hold the Bank liable for furnishing of the processed information / data /products thereof to other Banks /Financial Institutions / Credit Providers / Users registered as above. (h) That I have to complete further application for specific liability products/ services from the Bank as prescribed from time to time, and that such further applications shall be regarded as an integral part of this application (and vice versa), and thatunless otherwise disclosed in such further forms as prescribed, the particulars and information set forth herein as well as the documents referred or provided herewith are true,correct, complete and up-to-date in all respects. (i) That such further applications will require incorporation of the application form number, and / or such details as the Bank mayprescribe, to facilitate data management. (j) That I authorise the Bank to issue a Debit cum ATM Card to me. (k) That the issue and usage of the Debit cum ATM Card is governedby the terms and conditions as in force from time to time and I agree to be bound by the same. (l) That the terms and conditions of Debit cum ATM Card are liable to be amendedby the Bank from time to time. (m) That I unconditionally and irrevocably authorise the Bank, to debit my Account annually with an amount equivalent to the fee and charges foruse of the Debit cum ATM Card. (n) That continuation of the account with the Bank is at the sole discretion of the Bank and in case the Bank is dissatisfied with the conduct of theAccount / accountholder, the Bank has the right to close the account after giving me one month's notice or withdraw the concessions in to or any service granted to me orcharge the Bank's applicable rates for such services. (o) That the Bank may at its absolute discretion, discontinue any of the services completely or partially without any notice tome. (p) That in case of return of Account Opening Amount (AOA) cheques, for any reason whatsoever, the Bank would close the account without any reference to me. (q) ThatDCB – On The Go facility will be offered to customers whose account is an individually operated resident account. (r) That DCB mobile Banking will also not be available to NonResident Accounts. (s) That I hereby opt to enroll under Group Personal Accident Insurance Plan (“Plan”). The terms and conditions of the Plan have been duly explained by DCBBank and I have completely understood the same. (t) That I authorize DCB Bank to debit the above chosen premium amount from my DCB Bank Account towards the paymentfor this Plan. (u) That the insurance cover shall start on 1st day of the succeeding month of the premium amount debit in my DCB Bank Account (“commencement date”). (v) Thatthis insurance cover will be valid for a period of 1 (one) year from the commencement date, provided I continue to remain a DCB Bank account holder during this period. (w) Thatin case auto renewal is chosen without specifying tenure, policy will be auto renewed for a tenure of 1 (one) year by default and applicable premium amount debited from myDCB Bank Account. (x) That in the event of an admissible claim due to my death, my nominee shall be receiving the claim amount. (y) That DCB Bank shall not have any role in theclaim process and the claim shall be processed and settled by Royal Sundaram Alliance Insurance Company Limited (“Royal Sundaram”), as per the claim process stipulated byRoyal Sundaram, from time to time. (z) That the claim shall be processed as per the terms and conditions of the Master Policy No. PADCB00001 issued to DCB Bank by RoyalSundaram.This application is for Group Personal Accident Insurance Cover only. It is not a cover for Life Insurance or Mediclaim.Section 41 of the Insurance Act, 1938 – Prohibition of rebates -1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind of riskrelating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking outor renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to beacceptance of a rebate of premium within the meaning of this sub-section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishingthat he is a bona fide insurance agent employed by the insurer.2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.Signature of ApplicantRisk Classification* Kindly fill the following details:Expected Annual Turnover (`): Upto ` 1 lakhs Upto ` 10 lakhs Upto ` 50 lakhs Upto ` 1 CroreUpto ` 5 Crores Upto ` 10 Crores Upto ` 25 Crores More than ` 25 CroresExpected number of transactions in a month: Up to 20 21 to 50 More than 50Basis of Categorisation: Politically Exposed Person Domiciled in Risk Country Trust Sleeping PartnerHigh Risk ProfessionOthers (Please specify):Information: Politically Exposed Person due to position / status as:If Domiciled in Risk Country - Country Name:Nature of Business / Occupation:*Details of Customer’s Source of Funds & Estimated Net Worth:Income from Employment Income from Business Income from Investments Inherited FundsOthers (Please specify):Risk Classification of Account (L / M / H):Development Credit Bank Limited11

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